Session # F3 Behavioral Health Homes Study: Leading the Way to … · 2018-04-01 · Behavioral Health Homes Study: Leading the Way to Optimal Health for Individuals with Serious

Behavioral Health Homes Study: Leading the Way to Optimal Health for Individuals with Serious Mental Illness

Patricia Schake, MSW, LSW, Senior Director Program Innovation, Community Care Behavioral Health Organization

Cara Nikolajski, MPH, Senior Program Administrator, University of Pittsburgh Medical Center for High-Value Health Care, Pittsburgh, PA

Suzanne Daub, LCSW, Senior Director of Integrated Care Initiatives, Community Care Behavioral Health Organization, Pittsburgh, PA

Session # F3

CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas

Faculty DisclosureThe presenters of this session have NOT had any relevant

financial relationships during the past 12 months.

Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017

Slides and handouts are also available on the mobile app.

Learning Objectives

At the conclusion of this session, the participant will be able to:

Describe and discuss considerations for successfully implementing complex research designs in real world settings

Examine the role of stakeholder partnership in developing and conducting research

Apply lessons learned from the Optimal Health study; intervention model outcomes and research to their work

Bibliography / ReferenceKogan, J; Schuster, J; Nikolajski, C; Schake, P; Morton, S; Kang, C; Reynolds, C. Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness. Clinical Trials. Sept 28, 2016 epub; Feb 2017, volume 14.

De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011; 10(1): 52077.

Substance Abuse and Mental Health Services Administration. Wellness Campaign. 2012; www.promoteacceptance, samhsa.gov/10by10/sitemap.aspx. July3, 2012

Garces JPD, Lopez GJP, Wang Z, et al. Eliciting Patient Perspective in Patient-Centered Outcomes Research: A Meta Narrative Systematic Review. Washington D.C.: A report prepared for the Patient-Centered Outcomes Research Institute; 2012

Swarbrick M, Murphy AA, Zechner M, Spagnolo AB, Gill KJ. Wellness coaching: A new role for peers. Psychiatric Rehabilitation Journal. Spring 2011; 34(4): 328-331.

http://www.promoteacceptance/

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted

at the end of this presentation.

PCORI Optimal Health

• Community Care Behavioral Health, a large non-profit behavioral health managed care organization in Pennsylvania, leveraged its ongoing collaboration with healthcare, policy, community, and patient stakeholders to design and conduct a Patient-Centered Outcomes Research Institute sponsored study comparing the effectiveness of two behavioral health home interventions aimed at improving healthcare access and outcomes for individuals with SMI, a population that remains largely underserved.

– Brief overview of the execution of all steps of the study including stakeholder involvement in all aspects of research from conception to dissemination study, study design (mixed methods, cluster randomized trial, and unique challenges encountered in real world settings), implementation and outcomes.

– Lessons learned from conducting a large scale study (1,229 Medicaid-enrolled participants with approximately 600 in each intervention arm) to inform the audience of specific skills needed to develop and implement a complex research study in real world settings

– Discussion and questions

© 2017 Community Care Behavioral Health Organization 7

Behavioral Health and Wellness

• Adults with SMI are one of the most medically vulnerable populations

– 68% of adults with mental health disorders also have medical conditions

– High rates of undiagnosed, untreated, or poorly treated medical illnesses and difficulty accessing medical care

– High rates of premature death; dying as much as 15 to 25 years

younger than the general population

– Modifiable lifestyle choices and behaviors may contribute

(alcohol & tobacco use, poor nutrition)

© 2017 Community Care Behavioral Health Organization 8

Behavioral Health Home (BHHP)

• Community Care’s commitment to overall health & recovery-based programs

• Behavioral & physical health systems have historically failed to systematically address and support prevention and wellness, especially the most vulnerable populations such as adults with SMI

• Belief that BH providers are uniquely positioned to assist adults

with SMI in addressing whole health and wellness

9© 2017 Community Care Behavioral Health Organization

Community Care’s BHHP


• Services must be:

– Person/family centered

– Adhere to recovery principles

– Promote self-management skills

– Integrate into the individual’s recovery plan

• Individuals do not have to change existing providers or supports, but rather should enhance and build upon the individual’s provider and support network

• Integrating mental health and drug and alcohol care with physical health care creates good health outcomes

Community Care’s BHH Plus

• Successful early collaboration with Community Care & BH providers in North Central region of PA to address wellness through BHH model in 2010 with a focus on:

– Enhancing capacity of behavioral health providers to serve as health homes

– Comprehensive care management

– Care coordination and health promotion

– Linkage of service users to community resources


Study Overview: Optimal Health

12

• A multi-stakeholder collaboration to study the key components of the BHHP model

• Main partners include:– Community Care – UPMC Center for High-Value Health Care– University of Pittsburgh– Stakeholder Advisory Board– BHARP, NC and Chester Counties and

Providers• Principal investigators:

– James Schuster, MD, MBA, Community Care

– Charles (Chip) Reynolds III, MD, University of Pittsburgh

– Tracy Carney, CPRP, CSP, Community Care

• Supported by the Patient-Centered Outcomes Research Institute (PCORI)

© 2017 Community Care Behavioral Health Organization

Study Overview: What is PCORI?

• Patient-Centered Outcomes Research Institute

• Established in 2011 by Congress through the Affordable Care Act to support comparative effectiveness research to provide information about the best available evidence to help patients and their health care providers make more informed decisions about their care

• Focused on studying outcomes that matter to patients in real

world settings; robust stakeholder involvement a hallmark


Broad Stakeholder Involvement

• Strong emphasis on patient and stakeholder involvement in all stages of the study – from proposal development through implementation, and dissemination of results


Monitoring of Progress

Prioritization &

Funding

Formulation of

Research

Questions

Study Design

& ProceduresDissemination ImplementationData Collection

Analysis &

Interpretation

Foundational Execution Translational

Implemented under the guidance and support of a Stakeholder Advisory Board with implementation support from the UPMC Center for High-Value Health Care, BHARP, and Community Care

Broad Stakeholder Involvement

• Stakeholder involvement the key to addressing challenges encountered in implementing comparative effectiveness research in real-world setting


Monitoring of Progress

Prioritization &

Funding

Formulation of

Research

Questions

Study Design

& ProceduresDissemination ImplementationData Collection

Analysis &

Interpretation

Foundational Execution Translational

Stakeholder Advisory Board

• Representatives from our partnering counties, patients, providers, payers, academic and nonprofit community experts, and policy makers

• Convened semi-annually and ad-hoc by the PIs to:

– Monitor study progress

– Assess and advise the research staff on community needs and resources

– Identify opportunities for expanding outreach and dissemination

– Increase the visibility of the project in the community

– Provide feedback from alternative perspectives

Role of the Stakeholder Advisory Board


Optimal Health Providers


Pike

WarrenMcKean

Elk

Jefferson

Centre

Mifflin

Chester

Juniata

Huntingdon

Clarion

Provider Offices

Study Overview: Interventions

Comparative effectiveness study of two behavioral health home model approaches to improve the health status of individuals with serious mental illness, increase patient activation in care, and improve engagement with primary/specialty physical health care


Provider-Supported CareWellness nurses focused

on PH & wellness

(5 providers)

Self-Directed CareSelf-management

toolkits & resources

(6 providers)

Enhancing patient & BH

provider capacity to

address PH & wellness

Study Overview: Interventions

• Both approaches:

– Train case managers and peer specialists as wellness coaches/health navigators

– Establish an agency culture of wellness

– Utilize a high-risk disease registry with key indicators of PH

and BH needs


Study Overview: Data Sources


PCORI

Optimal Health

Participants

HealthChoices Eligibility Data

(Medicaid eligibility)

Self-Report Measures

(Patient activation,** health status,** hope,

quality of life, functional

status, satisfaction with care, social support)

Learning Collaborative

(LC) Data(Implementation

information)

Qualitative Data

(Serv ice user & prov ider interviews)

**Primary outcome

Administrative Data

(Demographic info)

Behavioral Health Claims

(BH diagnosis, utilization)

Physical Health Claims

(Engagement in primary/specialty care**)

Primary Data Sources Secondary Data Sources

Pharmacy Claims

(Medication utilization)

1229 part icipants

Study Overview: Demographics


Characteristic

Provider-

Supported

Self-Directed Total

N % N % N %

Total 713 58.0% 516 42.0% 1,229 100%

Age

(mean/range)43.47 19-72 42.37 18-76 43.01 18-76

Gender

Female

Male

428

285

60.0%

40.0%

341

175

66.1%

33.9%

769

460

62.6%

37.4%

Race

White

Black

Other

622

72

19

87.2%

10.1%

2.7%

487

21

8

94.4%

4.1%

1.6%

1104

93

27

90.2%

7.6%%

2.2%

Ethnicity

Non-Hispanic

Hispanic

710

3

99.6%

0.4%

512

4

99.2%

0.9%

1222

7

99.4%

0.6%

Diagnosis

MDD

Bipolar

Schizoaffective

Schizophrenia

Other

None

227

193

131

86

67

9

31.8%

27.1%

18.4%

12.1%

9.4%

1.3%

234

137

64

40

31

10

45.3%

26.6%

12.4%

7.8%

6.0%

1.9%

461

330

195

126

98

19

37.5%

26.9%

15.9%

10.3%

8.0%

1.5%

Findings Executive Summary

22

• Learning Collaborative/Implementation Findings:– Performance on all process/outcome goals improved over

time

– Provider-supported arm reported higher degree of achievement on all process goals after one year of implementation

• Qualitative Interview Findings:

– Little difference in findings between intervention arms

– Overall positive experiences participating in (service users) or implementing (providers) interventions

• Quantitative Findings:

– Intervention type (Provider-Supported vs. Self-Directed) has a differential impact on some patient-centered outcomes (treatment X time interaction effect)

– Both interventions positively impact several of our outcomes over time (change over time)

• Financial Findings:

– Indicative of long-term cost reductions in Provider-Supported (Wellness Nurse) sites, with some evidence of long-term decreases in Self-Directed (self-management navigator) sites

– Suggestive of increased short-term PH use at both sites, but more ambulatory and lower inpatient

• Lessons Learned:

– Stakeholder involvement in discussion of findings

– Mixed method design

– Additional analysis (financial

impact analysis conducted independent of PCORI sponsored research)


LC to Support Implementation


Structured approach for

change

Adopt best practices in

multiple settings

Uses adult learning

principles & techniques

Time-limited learning process

Shared learning and

collaboration

•Learning Sessions

Training Manuals

•Action Periods

Apply Skills Test Changes •Collaborative

Meetings

Ongoing TA & Support

•Measure Outcomes

Share Progress

Qualitative Interview Data: Svc. Users

24

• Shift in definition of health and wellness, away from vague/impersonal towards more personalized

• Increased awareness of interconnectedness of mental and physical health

• Overall favorable intervention experiences

• No major distinctions between arms –no evident differences in engagement in or satisfaction with interventions

• Most important factor leading to intervention participation was relationship with wellness coach

Code Name Round 3 # of Participants Round 2 # of Participants

Goal Exercise 16 17

Goal Eating

Habits/Nutrition

13 13

Goal Weight Loss 10 9

Goal Relationships 9 10

Goal Tobacco 9 13

Goal Medication 7 4

Goal Mental/Emotional

Health

7 10

Goal Other 7 0

Goal Unsure 7 9

Goal None 6 17

Goal General Activity 4 3

Goal Independence 4 3

Goal Physical/Dental

Health Appointments

3 6

Goal Starting 3 3

Goal Sobriety 2 1

Goal Social Services 2 9

Goal Sleep 1 4

Goal Cleaning 0 3


Qualitative Interview Data: Svc. Users


“We made a goal [for walking] a half mile. I go

and somet imes I go a mile. So we st art from the mile and t hen we go up.

If I didn’t make it and went back, t hen I t old her I’d make it up. So I

go and inst ead of doing t he mile, I do a mile and

a half. That way I keep myself ahead.”

“...Going t o the doct or and asking him about t he

Chant ix...I was afraid t o t ake it because it st raight says on t here, ‘if you have

depression, t alk to your doct or first .’...It didn’t seem t o have any bad effect on

t hat...Overall, it really helped me quit . It took

away t hat urge t o want the cigarette smoke.”

“I am eat ing a lot more fruits and veget ables. Cutting down what I’m eat ing. Trying t o watch my

calories. She [t he case manager] knows t hat I just started watching

my calories and she’ll ask me how t he calorie count ing is

going...she’ll encourage me.”

“I’ve act ually exceeded my

goal...the weight I’m at now, I haven’t been

since I was a young

t eenager...I lost 25 pounds in t he

beginning and I’ve act ually lost more

close t o 45. I feel like I

have more energy.”

Qualitative Interview Data: Providers

• Agency response:

– High degree of agency support for wellness coaching

– Establishment of culture of wellness

– Continued use of model post study implementation period

– Staff turnover problematic for maintaining wellness coaching continuity

– Worry about service user “relapse” when discharged from CMHC

• Provider response:

– Providers simplified/casualized wellness coaching to increase service user engagement

– Nurses often mentioned as most beneficial component of the model

– Providers often established their own wellness goal(s)



• Service user response (provider perception):

– Robustly positive impact on service user’s health/wellness

– Some service users resistant to wellness coaching due to mental illness severity or age (e.g., being set in their ways)

– Structural barriers (e.g., lack of access to health care,

community resources, transportation) limits success

• Physician response:

– Several providers indicated difficulties engaging with primary care providers (especially at interview time point three)




“We really need t o find a way t o keep t his program going for t hem because we

finally got t hem doctors. We can’t just say, ‘Oh, we’re sorry’ now. It ’s done so much for t hem...We know how important this is

for t he consumers...A gent leman in his late 50s, he has some int ellectual disabilities, and he was very anxious about get t ing t est ing for us. We wanted his t o get an

echo and a st ress t est...labs, x-rays...he is

now going t o get these t ests...and on t op of all t hat, he has lost about 36 pounds.”

“We had bet ter coordination of care and her hospit al visits decreased. Before I met her, she said she was

going [t o the hospital] once or t wice a mont h; now she might go once

every t hree months when her bronchit is flares up a little bit , but

she’s able t o come home t he next day or t he day after t hat so it’s not as

t raumatic...She sees t he wellness

nurse and she get s all of t he information she needs regarding

each specialist . And there was a t ime when she was here and monitored by t he wellness nurse, and t he nurse

said, ‘You need t o go t o t he ER because you’re not well, you’re

coughing, and your blood pressure is sky high.’ If she wouldn’t have come

in and had t hose t hings done...A

regular visit from back in t he day, she would have come in and she would say, ‘I’m fine,’ and I don’t know t hat

she would have made it .”

“He went from three packs a week t o one

pack a mont h, and he did t hat within six

mont hs...His goal within

t he next six months is t o quit smoking all

t ogether & not use t he e-cigarette.”

Quantitative: Patient Activation

• What is patient activation?

– Measures an individual’s level of engagement in their own health care; measured via the Patient Activation Measure (PAM)

– Past research suggests even a small increase in patient activation is associated with reductions in health care utilization and improved medication adherence

• Our findings:

– Provider-supported led to more immediate and stable improvement in patient activation

– Female gender is associated with quicker improvement in patient activation in the Provider-Supported arm


Quantitative: Health Status

• What is health status?– Health status measured with the SF-12, which measures both

perceived physical and mental health – The national mean score for SF-12 is 50; our participants scored

much lower than the national average– Research shows that even a small score change can impact mortality

rates and other health-related factors

• Our findings: – Mental health status score increased, particularly at month 6

(significant change over time) – Physical health status score decreased over time, particularly after

month 12 (significant change over time)


Quantitative: Health Care Utilization

31

Engagement in Primary/Specialty

Care

• Our finding: while the two

interventions did not differ significantly in their impact on this outcome, both showed improvement over time (significant change over time)

Emergent Care Use

• Our finding: two interventions were significantly different with regard to

their impact on ED use; Self-Directed started off with higher

utilization and decreased more drastically, Provider-Supported remained fairly stable over time

(significant treatment X time interaction effect)


Engagement - Primary/Specialty Care


Emergent Care Use


Quantitative: Quality of Life

• What is quality of life?

– Measured using the Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF) which assesses physical health, mood, relationships, and well-being, among other variables

• Our finding: Provider-Supported started off with a higher score

and the score peaked at 6 months. Quality of life score for Self-Directed peaked at 12 months


Findings Recap


Discussion

36

• Lessons learned

• Applicability to your work

• Key takeaways

• Describe and discuss considerations for successfully implementing complex research designs in real world settings

• Examine the role of stakeholder partnership in developing and conducting research

• Apply lessons learned from the Optimal Health study; intervention model outcomes and research


Next Steps

37

• Complete interpretation of study findings and develop final research report

• Dissemination – PCORI– Clinical trials– Manuscripts– Conference presentations– Stakeholder forums and results

materials – Optimal Health dissemination website– PCORI dissemination funding

opportunity

• Behavioral health home expansion


Behavioral Health Home Expansion

• Additional populations served: adolescents, opioid treatment programs

• Population Health LC ocused on hypertension & smoking cessation


Erie

Allegheny

Clarion

Forest

Warren McKean Potter

CameronElk

Jefferson

Clearfield

Blair

Centre

Clinton

Adams

Snyder

Union

Lycoming

Tioga Bradford

Columbia

Montour

York

Chester

Berks

Schuylkill

Luzerne

Wyoming

Susquehanna

Lackawanna

Wayne

Pike

Monroe

Carbon

Juniata

Sullivan

Mifflin

Huntingdon

Northumberland

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Documents

Session # F3 Behavioral Health Homes Study: Leading the Way to … · 2018-04-01 · Behavioral Health Homes Study: Leading the Way to Optimal Health for Individuals with Serious